Teaching psychodynamic formulation to psychiatric trainees.

Part 2: Teaching methods

Chris Mace and Sharon Binyon
APT 2006, 12:92-99.
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 Advances in Psychiatric Treatment (2006), vol. 12, 92–99

Teaching psychodynamic formulation

to psychiatric trainees
Part 2: Teaching methods
Chris Mace & Sharon Binyon

Abstract Teaching methods to help students appreciate the value of psychodynamic formulation and to become
more skilled in producing formulations are described. These are closely related to the four levels of our
model formulation, each level corresponding to a set of competencies through which students should
normally progress. Accurate diagnosis of a student’s current capabilities and needs is crucial to effective
teaching. Teaching methods at each level are illustrated through detailed reference to a case example.
The usefulness of small-group discussion for assimilating clinical material within a clear framework is
emphasised throughout.

This article completes Mace & Binyon’s discussion of psychodynamic planning. Most doctors agree with this aim, but in
formulation. Readers should refer to their previous article (Mace &
Binyon, 2005) for the basics of formulation, including a description
practice it can be a daunting prospect, adding a new
of the four-level model and the three psychodynamic dimensions of dimension to the skills required of a practitioner.
operationalised psychodynamic diagnostics. At its root is the need to be able to understand
patients’ reactions to their circumstances. Although a
In Part 1 of this overview (Mace & Binyon, 2005) we consultation with a doctor may seem commonplace
described psycho­dynamic formulation in terms of to us, for a patient it is often associated with fear,
four levels of attainment: pain and anxiety. Little wonder, then, that they do
not always respond in what we consider a ‘rational’
1� recognising the psychological dimension; way.
2� constructing an illness narrative; Most modern medical school curricula place
3� modelling a formulation; emphasis on seeing the patient as a whole person
4� naming the elements. existing in their own social and psychological
Here we concentrate on educational requirements at environment rather than as a specimen under a
each level and teaching methods that are appropriate microscope. This is a widely accepted educational
to develop skills in formulation. Although we focus philosophy (e.g. General Medical Council, 2003),
primarily on the needs of psychiatrists in basic and but not always evident in practice. Beyond familiar­
higher training, we believe formulation skills to be isation with mental disorders, psychiatric education
useful for all doctors. Preparation should therefore has a lot to offer in encouraging students to consider
begin during undergraduate teaching. psychological aspects of their patients’ problems.
Knowledge of the basic level of psychodynamic
formulation can be extremely helpful in recognising
Reading the person in the patient the personal in medicine.
Within clinical psychiatry, the needs of people
Many changes are occurring in the practice of referred to consultant teams are rarely simple. If a
medicine for the 21st century, one of the more diagnosis of depressive illness and the judicious use
positive being the emphasis on treating patients in of support and medication were enough, then, given
a holistic way and involving them in their treatment the sophistication of most primary care services, this

Chris Mace is consultant psychotherapist and Director of Medical Education at South Warwickshire Primary Care Trust (The Pines, St
Michael’s Hospital, Warwick CV34 5QW, UK. E-mail: C.Mace@Warwick.ac.uk) and honorary senior lecturer in psychotherapy at the
University of Warwick. He is a training programme director in psychotherapy and has a research interest in assessment for psychotherapy.
Sharon Binyon is a consultant in adult psychiatry with a special interest in psychotherapy, and Associate Medical Director to North
Warwickshire Primary Care Trust. She is clinical tutor and scheme organiser for the Coventry & Warwickshire SHO training scheme.

92
 Teaching psychodynamic formulation: Part 2

is likely to have been provided already. Anybody This should not provide a licence to turn a teaching
referred to mental health services will need careful session into a surgery or confessional, but, in
appraisal of their needs and psychological and social addition to engaging interest, it will help the skilful
functioning that takes account of their outlook and teacher to select exemplary material that relates to
likely responses and resistances to treatment. some of the interests of those in the room.
As in other situations where the primary aim is
to develop clinical skills, we believe a small-group
Using the need to know format to be optimal. Athough it is possible to
provide material on general principles in a more
Teaching of psychodynamic formulation should didactic setting, such as a course lecture for the
be an integral part of the teaching of psychiatric College’s membership examinations, the teaching of
assess­ment. At each level, it will be important to formulation requires students to be free to prepare
motivate the student group and to engage their ideas through small-group discussion and to interact
willing­ness to learn. This is often best done by with the teaching clinician in a situation that allows
relating formulation to clinical predicaments that everybody to contribute several suggestions. This
are challenging the students at the time. It may is likely to mean a maximum of eight students for
involve using dynamic concepts to shed light on a 1 h session.
an unexpected reaction, as in David Malan’s (1979)
discussion of why a young child may turn away
from her parents when they visit her for the first time Principles of teaching
in hospital. Alternative material that is useful here
is George Vaillant’s (1992) examination of why an Although the content and sophistication of teaching
infertile woman who has undergone a hysterectomy will vary at each level of attainment, the basic
may write letters of complaint (or behave in other educational principles for teaching psychodynamic
unexpected ways) after the operation. Material formulation are the same. These are outlined in Table
derived from general hospital practice or primary 1. First, existing knowledge is activated through an
care can be very persuasive with undergraduates exploratory discussion, interspersed with reminders
whose fears of psychiatry otherwise prompt them to and prompts about the nature of formulation. Active
split the experience off from the rest of their clinical questioning around themes outlined in Part 1 (the
education. difference between formulation and diagnosis; the
With trainee psychiatrists, appreciating the uses aims of formulation) can be helpful, as can a group
of formulation discussed in Part 1 of this overview attempt to formulate some pre-prepared material.
can assist motivation to learn the process. Why Doing this permits a quick diagnosis of the group’s
won’t Mrs W talk to me? Why did Mr X shout at needs in terms of the four levels of attainment listed
the specialist registrar during the ward meeting? in our opening paragraph. (These should never
With senior trainees, questions about what action be assumed from the professional standing of the
to take will become more prominent. How will students.)
Ms Y react to being in a group at the day centre? In rough terms, work at level 1 (recognising the
What is the most useful thing for the ward team to psychological dimension) is required if it is apparent
understand about Mr Z so that he cuts himself less? that the students fail to appreciate patients as people
For experienced psychiatrists who have long-term with feelings who understandably react in all kinds
relationships with patients, yet other questions of ways. Level 2 (constructing an illness narrative)
arise. Why do I feel utterly helpless after 5 minutes would be mastered during early experiences of
with Mr A? How could I have been taken in by psychiatry (including working in foundation year
that? Why is there never any time left to discuss posts). Level 3 (modelling a formulation) represents
Miss C? Finally, the psychiatrist providing ongoing the goal for the early years of psychiatric training.
psychodynamic treatment needs tools that help to Level 4 (naming the elements) is essential for higher
map the tasks within the therapy. What kinds of training in psychotherapy, but is certainly desirable
new experience are likely to be anxiety-provoking,
but potentially liberating, for this person? Are there
ways of approaching this person that are likely to Table 1 Cycle of teaching
reduce resistance rather than arousing it? Setting Task
Whatever the students’ level, there is no better Small-group seminar Activate previous knowledge
motivator for learning more about formulation than
Small-group seminar Add theory
connecting with an existing need to know. A few
Clinical experience Practise the application
minutes spent discovering some of the dilemmas
Supervision Consolidate
currently faced by students can pay dividends.

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Mace & Binyon

for specialists in other branches of psychiatry in the Method

later stages of training.
It is important that some didactic teaching has
already been provided on psychological factors
Level 1 in illness. To develop the students’ clinical skills
at this level, it is useful to demonstrate a generic
The aim at this level is to ensure that students method of assessing personal background alongside
achieve a basic psychological mindedness. At any psychological function. It is neither important nor
level, dynamic explanation is possible only if the necessarily helpful to use a particular psychodynamic
student tries to enter into the patient’s experience theory at this stage. The emphasis should be on good
and to see apparently pathological or even bad history-taking to tease out key influences during the
behaviour as an adaptation to unmanageable patient’s development and their ways of coping,
feelings. Level 1 teaching should therefore help whether or not these are seen as adaptive. This
the student to enter the patient’s feelings and requires cultivation of the capacity to use interviews
understand their motivations. It will not lead to to empathise with and understand the patient, rather
a cogent formulation, but prepares for the later than simply to obtain information.
stages of formulation training and helps to prevent Teaching can begin by encouraging students to
irretrievable breakdown in relations with patients imagine the subjective experience of past patients.
owing to intolerance and misunderstanding. This helps them to practise empathic techniques that
allow them to move between the patient’s subjective
Method experience and their own objective analysis of the
patient’s position. The main purpose is to ensure
How this is achieved may need to be tailored with that students recognise how psychological factors
sensitivity and flexibility to the individual student. may influence presentation of disease and use this
Rather than interrogate an already confused and recognition in their narrative account of the patient’s
insecure student, one strategy might be to discuss illness. These factors will include the reactions of
some case histories to illustrate the difference others (including the student) to the patient, which
between a purely diagnostic and a subjective will probably be incorporated in material that is
understanding of a presentation. discussed.
The case histories chosen should be relatively However, the real challenge at level 2 is to reinforce
straightforward in diagnostic terms. They should this teaching through apprentice-style learning on
also include strong indications from the descriptions individual patients as the student encounters
of the patient’s behaviour and choice of words of them. This is likely to be heavily dependent on the
how he or she was feeling, and sufficient information enthusiasm or otherwise of consultant educators.
from the history to suggest several reasons for why It is desirable that learning derived from each new
a particular feeling was present. patient history be shared with a number of students.
Discussion should centre on the patient’s likely An excellent forum for such sharing is a weekly case
feelings, why they might have been experiencing discussion group in which students present cases
these and why they might have taken apparently reports to a psychologically minded teacher who can
irrational actions. As the students begin to realise then assist in drawing out relevant factors.
that a patient’s speech and actions are intelligible in
the context of that person’s subjective experience, the Case vignette: Alice
teacher should prompt and nurture their curiosity A 25-year-old woman, Alice, presented to her general
about others’ feelings and motivation. practitioner (GP) with some symptoms of depression:
low mood, anhedonia, comfort eating, difficulty
sleeping and thoughts of self-harm that on several
Level 2 occasions became overwhelming and led to drug
overdoses. She had taken two overdoses in the past
The objective at level 2 is to develop an appreciation month that turned out to have been larger than she
of the continuity between an individual’s inner admitted at the time. A diagnosis of depression was
life and their behaviour when ill, including their made and an antidepressant started. She failed to
respond and the GP referred her to an out-patient
attitudes and response to treatment. Level 2 teaching
psychiatric clinic for assessment.
helps students to develop confidence in constructing
It is found that Alice has felt ‘depressed’ to a greater
a narrative account of a patient’s difficulties that is or lesser degree for as long as she can remember.
informed by their subjective experience. Successful Despite this, she has managed to cope in the past and
assimilation can also be expected to bring benefits gained ‘A’ levels before joining a managerial training
when motivating patients to undertake or persist programme for a well-known retailer. Things have
with treatment and in other key communications. worsened recently following the break-up of a 2-year

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 Teaching psychodynamic formulation: Part 2

relationship with a man. She is finding it difficult to to act in ways that would not actually be helpful?
come to terms with this, despite support from a number For example, a helper drawn into identifying with
of friends. Further questioning reveals that her father Alice’s mother might be dismissive and rejecting,
died when she was 5 years old. She has vivid memories whereas one who identifies with her father might
of him and missed him terribly at the time. She is
become very anxious and solicitous.
the middle of three children, and the only girl. Since
Through a careful attempt to understand Alice’s
childhood she had felt that her mother always favoured
the boys and had found it difficult to be close to her. feelings and reactions, during which the students’
Her mother had experienced episodes of depression empathy, curiosity and imagination are engaged,
and Alice thinks she was in hospital for a while after an account of her presentation and current problem
her father’s death. She has a recollection of being cared emerges that links formative experiences, such as
for by an aunt for several weeks. losses and parental illness in her childhood, with her
In his referral letter, the (50-year-old male) GP characteristic ways of coping as an adult.
communicates a great sense of urgency. He also rings
up several times to speak personally to the assessing
doctor to convey his concern and to seek feedback. Level 3
The assessing doctor and the student (both younger
females) did not pick up any of the same sense of
The objective at this level is to produce a structured
desperation when they saw Alice. To them, she had
account that not only makes sense of the patient’s
seemed very much in control, almost cold.
predicament, but informs the planning of treatment
At this level it would be necessary to explore and predicts some likely responses to it. Senior
with the students on an almost intuitive basis two house officers (SHOs) will be used to summary case
questions. formulation in terms of predisposing, precipitating
First, why was Alice presenting in this state now, and maintaining factors. Psychodynamic aspects
rather than at any other time? The discussion is can usefully be structured in a similar way (see Part
likely to look first at recent precipitants, such as the 1 of this overview). Senior house officers will also
coincidence of her depression with the ending of the have an outline knowledge of some of the theories
relationship with the boyfriend. Further exploration that underpin psychological therapies, although
might consider the nature of this relationship. How neither breadth nor depth of knowledge can be
was he viewed by her? What kind of expectations assumed. Once the predisposing, precipitating
were evident? Are these characteristic of most and maintaining factors have been set out, we
relationships of people at that stage of life, or is recommend that available theoretical knowledge be
there any sense that they were influenced by earlier harnessed in summarising apparently contradictory
events? In this way, participants in the discussion aspects of the patient’s responses in terms of one or
might make links between the pain of losing a first more underlying conflicts.
boyfriend on whom she had allowed herself to
become exclusively dependent – for guidance as Methods
well as emotional support – and the pain she felt
on suddenly losing a father who was everything Background teaching is now likely to include familiar­
to her. isation with the way in which psychodynamic
Second, why were the reactions of the GP so thinkers have conceptualised the unconscious
different from those of the assessing doctor? It is mind and human motivation. It should include
likely that Alice behaved differently in the two the contrasts between models based on theories
consultations. Discussion of what is known about of instinctual drives and object relations. This will
this can lead to an assessment of the ways in which provide trainees with a greater range of ways in
her reactions to men and women differ when she which to understand and discuss conflict, even if
feels in need of support from them. This in turn the theories and concepts invoked are incompletely
may prompt questions about her past experiences. assimilated.
From what is already known, Alice’s father ’s We have found that it is important to keep SHOs’
responsiveness and their special friendship contrasts under­standing continuously grounded in real
with her sense that her mother was not interested situations. Even the teaching of psychodynamic
and would desert her in her hour of need. This point theory should not lead them away from what they
is important in understanding Alice’s needs and are learning intuitively through experience. On
responses, and the discussion might consider the a day-to-day level, they need to be encouraged
implications for future management of her illness. to look for and think about the psychological
How might she be expected to behave towards aspects of all the cases they encounter. All SHOs
different helpers? What emotions might she arouse should now be attending a group in which this is
in those trying to help her? Could these lead them encouraged. This may be a dedicated case-discussion

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Mace & Binyon

group, as recommended for first-year trainees illuminate discussion of the interaction, and theories
in successive College guidelines for training in of personality and psychosexual development might
psychotherapy (Royal College of Psychiatrists, 2002), be introduced in going beyond what is immediately
or a psychotherapy supervision group in which the reported to discuss conflicts that underpin Alice’s
trainee is an observer (being as yet unready to have experience and actions.
personal responsibility for cases). Group discussion of the situation presented by Colin
In such group meetings trainees can develop encourages participants to discriminate between
their practical skills at formulation by re-engaging psychodynamic factors that have predisposed to
previous learning concerning the value of the Alice’s presentation and those that have precipitated
narrative perspective and its practical importance and maintained it.
in understanding clinical interactions. We therefore During the discussion, the precipitation of her
encourage SHOs to bring to these sessions cases recent depression is linked to loss of the relationship
that have disturbed them in some way. Often, a with Barry. The exclusivity of this relationship and
reflective exploration of a patient’s psychopathology her passivity within it, as well as its resonance with
and functioning enables trainees to understand in a the traumatic death of her father in childhood,
are commented on. In looking at other aspects of
way that is immediately helpful why they are being
her predisposition to depression, its recurrence is
affected by that patient. To build on this, trainees examined. Previous episodes are found to have
should aim to structure their observations in order coincided with times in her life when crucial supports
to arrive at a more cogent formulation in which the have been removed, for example when friends moved
contributing factors are critically evaluated and a away. When she was aware that she was becoming sad
compact summary of underlying conflicts is stated. she struggled to cope, but quickly became filled with
As an example let us consider an SHO who pessimism and despair. The group links this with her
has a personal relationship with Alice, whom we experience of having a mother whose depression left
introduced above. her unable to cope and who was unavailable to help
her find the resources to accept and assimilate her own
An SHO, Colin, reports to a discussion group that feelings, rather than remaining terrified of them. These,
he is aware of a strong need from a new patient for of course, include aggressive feelings, which it was
things to be made better for her. He has enquired impossible for Alice to express towards either of her
more about the pattern of her adult relationships parents and which she now habitually buries.
and discovered that her ex-partner Barry was some The discussion switches to Alice’s defences and
15 years older than her. In this relationship, she had how these not only predispose to, but maintain, her
been very dependent, preferring all decisions to be depression. Her fear of facing the pain of loss and her
taken by Barry and tolerating sexual relations in pattern of turning aggressive feelings against herself
order to feel loved. Even after he left her, she voices number among internal maintaining factors that are
disappointment rather than criticism of him. There identified.
appeared to be a sharp contrast here with her persona Finally, the group discusses external maintaining
at work, where Alice described herself as a high-flyer factors. It is noted that Alice’s tendency to be extremely
on her management training scheme. It also emerges passive in close relationships (and to have these
that her father’s sudden death was the result of a car relationships end when her partners fail to cope with
crash, just after what Alice remembers as an enormous her expectations for unquestioning but unreciprocated
row between her father and her mother. She recollects care) reinforces her internal psychological situation.
how her mother shouted that she never wanted to Encouraged to think about the nature of underlying
see her father again. Alice admits she has blamed her conflicts, the trainees comment on the split between
mother for her father’s death, although she has never a very autonomous self that strives for success and
said so openly, and she feels very unsettled whenever independence from others and a needy self that is felt
she senses anger around her. by Alice (and by them) to be insatiable. There seems
to be a primary conflict for Alice over the autonomy
We begin to see a complex picture emerging that she can maintain in relation to others. There are other
will help in understanding Alice’s contradictory kinds of psychodynamic conflict evident here too. Her
functioning, as well as her ability to compart­ inability to move beyond very dependent relationships
mentalise her life and to be very different in different with men whom she idealises to a sexually mature
circumstances. partnership is apparent from the pattern of her
relationships. She also experiences internal conflict over
To understand why she is reacting to the SHO as
the experience and expression of aggressive feelings.
she is requires a systematic attempt to distinguish
between predisposing, precipitating and maintaining The primary teaching emphasis here is on
dynamic factors. Theoretical ideas should be recognising conflict and its effects. Different terms
introduced as appropriate, letting them be taught (such as the false self, depressive anxiety and the
through illustration during the discussion. Concepts Oedipus complex) can be introduced in discussion,
such as transference and countertransference can according to the trainees’ readiness.

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 Teaching psychodynamic formulation: Part 2

The dynamic understanding that has now been trainees must also be able to monitor and recall
reached facilitates predictions regarding practical their own experiences, as these may help them to
clinical questions. As discussed in Part 1, these will identify patterns of interaction and hidden affects
include the part psychotherapy could play in the in the patient.
management of Alice’s illness, the form it might take Such interview skills are accompanied by a
and her likely responses to it. The formulation that more developed understanding of psychodynamic
has been modelled here suggests that Alice’s coping theory, so that a patient’s enduring traits, patterns
self might resist invitations to enter therapy, and that of interaction and experienced conflicts can not only
once a relationship with a therapist is underway there be labelled appropriately, but appraised in terms of
is a risk that she will become passively dependent their severity. This will require extended teaching
and very demanding. This should influence both on the principal psychodynamic models of the
the selection of the therapist and the supervision of personality, supported by their regular application
the subsequent work. In practice, the implications to clinical situations in seminars led by experienced
extend well beyond this, however. psychotherapists.
Alice does not attend her first appointment for psycho­
therapy assessment, but forms an attachment to a male Method
community psychiatric nurse, Dennis, in the community
mental health team. She tells him that she feels he is The OPD system is especially well suited to
more helpful than anybody else and he agrees to see group learning because it involves several distinct
her regularly. Initially flattered, Dennis subsequently operations, each requiring the recording of
becomes alarmed when Alice starts telephoning him
observations and judgements. These operations can
when he is on call, demanding additional meetings.
He brings this back to his team meeting.
be isolated and given selective attention according
to students’ needs. Group discussion and rating of
There is now a collective need for Alice’s behaviour examples, with constant reference to definitions and
to be understood and for Dennis to extricate himself illustrations in the OPD manual (OPD Task Force,
in a way that does not further traumatise her. An 2001), facilitates mastery of the various procedural
ability to formulate Alice’s needs psychodynamically rules. Psychodynamic formulations are produced
might help the team to understand how this once clinical observations have been translated
difficult situation with a patient has developed into separate statements concerning structure,
and to respond to it. However, prerequisite to a interpersonal relations and conflict. Refinement
psychodynamic formulation is the team’s ability to of each of these requires slightly different group-
see their own responses in psychodynamic terms learning experiences.
and to understand the importance of boundaries, the
pull of ‘special’ patients and the power individual Interpersonal relations
team members always have to sabotage others’ work
in the treatment programme. It can be helpful to consider interpersonal relations
first, as this makes full use of personal observations
and trainees’ own feelings. The process involves
Level 4 identifying the most characteristic experiences for
the patient or for others from descriptive information
At level 4 the aim is to construct a comprehensive and countertransference (see Part 1: Box 5).
case formulation that not only can inform care Discussion should first refine a shortlist of the most
planning, but that explains the nature and severity of characteristic forms these interactions take (regularly
the patient’s difficulties in terms that will be widely referring to clinical observations). Each trainee
understood. The operationalised psychodynamic should record their first thoughts using a copy of a
diagnostics (OPD) system (OPD Task Force, 2001) structured checklist (OPD Task Force, 2001) before
that we introduced in Part 1 provides a useful and the seminar leader attempts to draw up a consensual
very teachable method for this. version restricted to two or three types of interaction
By this stage it is hoped that the trainees will have in each category. The group then considers how these
developed the fairly sophisticated skills necessary interrelate to produce an interpersonal formulation
for detailed formulation. These include a capacity to in the shape of a sequence of interactions.
undertake full psychodynamic enquiry during one
or more assessment interviews, and to identify and Structure
flexibly pursue necessary lines of investigation. As a
result, judgements about the patient’s experience and Consideration of structure entails assessment
personality can be attempted that are supported by of the level of integration a patient shows with
clear historical evidence. Throughout an interview respect to the six aspects it encompasses (see

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Mace & Binyon

Part 1: Box 4). Detailed keys assist in the making of The formulation of cyclical interpersonal patterns
such judgements, which demand constant referral in this way can be of considerable practical help
back to knowledge of the overall pattern of a in psychiatric management and they should be
patient’s affects, defences, relations with others and discussed during teaching. For instance, this
management of themselves. In group discussion, formulation might have helped Colin to anticipate
familiar information is reassimilated and used the pull to be overprotective towards Alice and to
in attempts to reach consensus on each of these establish clear boundaries in his work with her that
judgements. did not collude with her expectation that he would
either take care of everything or reject her.
Conflict By clarifying areas in which intentions are likely
to be misunderstood and the ways a given patient
The final OPD dimension to discuss is conflicts is most likely to apply pressure on staff to act out
within the patient (see Part 1: Box 6). The group of role, formulations can also help staff teams to
should consider not only which kinds of conflict are maintain consistent and therapeutic boundaries in
present, from their understanding of the patient’s their work.
inner world, but also select those that have been
most disabling, from their knowledge of the patient’s Structure Reflection on the six structural dimensions
functioning. (Part 1: Box 4) shows considerable consistency in
the lack of integration that is evident within Alice.
Relating OPD to the example of Alice Self-perception is compromised by inconsistent
identity; self-regulation fails at times of self-
In the case of Alice, a good deal of material is already punishment and fear of negative affects; defensive
available from of her history and mental health operations demand considerable distortion of
professionals’ experiences of being with her. (As her representations of herself and others through
with level 3 formulation, it is not essential to have splitting and idealisation; perception of others grants
conducted a formal assessment for psychotherapy in them little autonomy, and her capacity for empathy
order to produce a cogent formulation. It is essential, is quite restricted; attachment is compromised by
however, to have accounts of how professionals the lack of internalised good objects alongside the
have felt while talking to the patient.) This material dominant fear of losing her external good objects.
is sufficient to attempt a first formulation using the The degree of misunderstanding that has arisen in
OPD system, with the proviso that revision may be the short exchanges with referrers suggests that her
necessary as more information becomes available. communications may be equally poorly integrated,
but this is best decided through direct experience.
Interpersonal relations In terms of her inter­actions,
Overall, and despite Alice’s apparently promising
Alice tends to see others as either ignoring of her or
career and tendency to talk very confidently about
unreliable, and she feels that she gives into others
her abilities as a high-flyer, integration is consistently
while blaming herself. Others’ experience of her,
in the low-to-moderate range. Should psychotherapy
however, is that she is either assertive or clinging,
be considered as a treatment option for Alice, this
while they find themselves feeling very protective
will have a bearing not only on its aims, but also its
or wanting to cut off from her. These cyclical
intensity and duration.
interrelations are illustrated in Fig. 1.
Conflict Alice exhibits some conflict in nearly all
of the seven areas listed in the OPD system (Part 1:
V Box 6). This does not make them equally significant.
In Alice’s case, the tension between wishes for
Self as: Others as:
appeasing others, giving up
dependence v. autonomy and the Oedipal/sexual
Alice’s devaluing or protecting conflicts evidenced seem to have the greatest effect,
experiences self being central to her presentation and her evident
V

difficulty in being able to recover.

Others’
V

experiences Alice as: Self as: Conclusions

asserting herself or protecting
trusting/clinging or recoiling
We have sought to demonstrate why the teaching
V of psychodynamic formulation is important at
all levels of medical training. The methods used,
primarily small-group teaching and supervision,
Fig. 1 Summary of interpersonal relations.
are substantially the same at each level. However,

98 Advances in Psychiatric Treatment (2006), vol. 12. http://apt.rcpsych.org/

 Teaching psychodynamic formulation: Part 2

the emphasis and curriculum change according to 3 The OPD system can be learned from:
trainees’ previous professional development and the a� correspondence courses
objectives at each stage. b� case discussion
c� a DSM–IV supplement
d� a published manual
Declaration of interest e� an interactive website.

4 Basic psychodynamic formulation skills are useful

Since this article was written, C.M. has joined the for:
UK OPD Task Force. a� medical students
b� general psychiatrists
References c� pharmacists
d� foundation-year doctors
General Medical Council (2003) Tomorrow’s Doctors:
e� general practitioners
Recommendations on Undergraduate Medical Education. London:
GMC.
Mace, C. & Binyon, S. (2005) Teaching psychodynamic formulation 5 Common errors in formulation include:
to psychiatric trainees. Part 1: Basics of formulation. Advances a� being excessively descriptive
in Psychiatric Treatment, 11, 416–423. b� containing inadequate analysis
Malan, D. (1979) Individual Psychotherapy and the Science of c� being too specific to the particular patient
Psychodynamics. London: Butterworth.
OPD Task Force (2001) Operationalized Psychodynamic Diagnostics:
d� providing an incorrect diagnosis
Foundations and Manual. Kirkland: Hogrefe & Huber. e� being pejorative about the patient.
Royal College of Psychiatrists (2002) Requirements for Psychotherapy
Training as Part of Basic Specialist Psychiatric Training. http://
www.rcpsych.ac.uk/traindev/postgrad/ptBasic.pdf
Vaillant, G. E. (1992) Ego Mechanisms of Defense: A Guide for
Clinicians and Researchers. New York: Basic Books.

MCQs
1 SHOs should be able to:
a� assess a patient’s integration
b� list precipitating factors
c� take a personal history
d� identify maintaining factors MCQ answers
e� teach formulation to others.
1 2 3 4 5
2 Formulation is taught in small groups because: a F a F a F a T a T
a� it is easy to video the discussion b T b T b T b T b T
b� students’ differing needs can be accommodated
c T c T c F c F c F
c� links with a range of practical experience can be
examined
d T d F d T d T d F
d� it makes role-play less embarrassing e F e T e F e T e F
e� they encourage frank discussion.

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